Low-level personnel un-trained in decision-making end up making discretionary medical choices

With no requirement for healthcare providers to care for uninsured patients seeking routine medical attention, frontline staff -- from clerks to insurance verifiers -- are the gatekeepers, deciding who is seen by the physician and who is turned away, according to research conducted at the University of Illinois at Chicago.

"Nonmedical personnel play a significant role in decisions affecting access to care for indigent patients," said Dr. Saul Weiner, assistant professor of medicine and pediatrics at the University of Illinois at Chicago College of Medicine, and lead author on the study.

Published in Medical Care, a leading journal in healthcare studies, the study found that at three medical centers in the Chicago area (one for profit, one not-for-profit and one a public institution), policies were ambiguous about what to do when uninsured patients cannot afford required prepayments. As a consequence, low-level personnel who are not trained in decision-making end up making discretionary choices, particularly when the organizations' priorities conflict.

Seventy-one percent of the staff Weiner and his colleagues interviewed reported that they did not turn patients away. The remainder said that they did so on occasion.

"Each year, millions of uninsured individuals in the United States seek routine healthcare services that they cannot afford," Weiner said. "While the Emergency Medical Treatment and Active Labor Act requires service in emergency rooms, no such law governs non-emergency care."

"The goal of the study was to examine the role of front-desk clerks at large urban medical centers who are charged not only with their employers' mission of caring for those in need, but also securing payment -- goals that clearly conflict when the patient is indigent."

At the three medical institutions, Weiner said, policies were incomplete, inapplicable, or had not been circulated among the frontline staff. For example, at one site, the policy required the clerk to request 50 percent of the cost of service if the patient was unable to pay the balance in full. However, it gave no guidance on what to do if the patient couldn't afford even the 50 percent.

Those kinds of ambiguities left decisions on healthcare access to the front-desk staff.

These staff were often advocates for indigent patients, going out of their way to argue that a patient should be admitted or classifying the case as "insurance pending" rather than "self-pay." In fact, Weiner found, none of the clerical staff at the lowest level of the pay scale reported ever having turned a patient away. These individuals also tended to be those who were sympathetic with the patients' plight -- some of them having previously been uninsured themselves.

By contrast, 39 percent of the more senior admitting staff (supervisors who are responsible for controlling costs and ensuring payment and who have less patient contact) said they had at times denied access to care, doing so for pragmatic reasons and with regret.

"The data suggest that decisions about access to healthcare are the product of a network of unwritten rules and understandings and the preferences of staff as they interface with individuals who are attempting to become or remain clients of a reluctant bureaucracy," Weiner wrote in his study.

"If this approach is widespread, then concerns arise about whether patients who are getting care are, in fact, those with the highest need or, rather, those best able to negotiate within such a system."

Co-authors of the study were Margaret LaPorte, in the UIC College of Urban Planning and Public Affairs, Dr. Richard Abrams, at the Rush University Medical Center, Dr. Arthur Moswin, at Michael Reese Hospital, and Richard Warnecke, in the UIC School of Public Health.

The study was funded by The Robert Wood Johnson Foundation, the nation's largest philanthropy devoted exclusively to health and healthcare.

For more information about the UIC College of Medicine, visit http://www.uic.edu/depts/mcam/.